Conquering Incontinence: A New and Physical Approach to a Freer Lifestyle

by Peter Dornan

Overview

Rooted in a deep understanding of physical health, this guide offers a range of treatments and exercises designed to help those who suffer from incontinence achieve greater freedom and more confident lifestyles. Utilizing important new research, this practical guide encourages incontinence victims to engage in a vigorous routine of physical activity designed to increase circulation and muscular control of the abdominal and pelvic region. Building on that base of good physical health, patients are then emboldened to make the lifestyle changes necessary to achieve lasting relief from the stigma associated with incontinence.

Product Details

ISBN-13:	9781741153378
Publisher:	Allen & Unwin Pty., Limited
Publication date:	06/01/2004
Sold by:	Barnes & Noble
Format:	eBook
Pages:	132
File size:	687 KB

About the Author

Peter Dornan has been a physiotherapist in the fields of sports injuries and manipulative theory for more than 35 years.

Read an Excerpt

Conquering Incontinence

A New and Physical Approach to a Freer Lifestyle

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By Peter Dornan

Allen & Unwin

Copyright © 2003 Peter Dornan
All rights reserved.
ISBN: 978-1-74115-337-8

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CHAPTER 1

How it all works

The urinary system: An overview

The urinary system is composed of four major parts: the kidneys, the ureters, the bladder and the urethra.

The urethra extends from the neck of the bladder and, in the female, exits the body in front of the vaginal opening; in the male, it passes through the prostate gland and exits at the end of the penis (see Figure 1.1).

The kidneys, situated in the flank area under the ribs on either side of the body, filter water and waste material from the blood to form urine. The kidney excretes what the body no longer needs, and channels this urine through a long narrow tube, the ureter, to where it collects in the bladder.

The bladder really is a reservoir, or storage chamber. Its walls are composed of special cells which become thick and muscular when empty. As the bladder fills, the walls stretch and become thinner; full capacity is reached at around 500 millilitres. As the bladder reaches about 40 per cent capacity — roughly 200 millilitres — an initial message is triggered telling the brain that it is time to empty. At this stage, the brain can then make a conscious decision to either hold or release the contents. As the bladder becomes fuller, the messages increase in frequency to the extent that a strong urge to pass urine — even to the point of pain — may be experienced (the crossed leg stage). Some people (about 10 per cent of the population) have bladders that over-respond to these messages and don't allow the bladder muscle to relax in order to accommodate a reasonable quantity of urine. These bladders are referred to as unstable or over-active.

For urine to be released through the urethra, the urinary sphincter must relax. (The sphincter is a strong ring of muscle which forms a tight cuff around the urethra.) After voiding, the sphincter then contracts (or tightens) again. The muscle, often called the internal sphincter, is comprised mainly of slow-twitch muscle fibres. This enables the sphincter to stay continually working — that is, it allows the sphincter to maintain continence by ensuring urethral closure for long periods.

This muscle is generally compromised by radical prostatectomy and takes time to recover. It fatigues early during the recovery process — which is why most leakage often occurs during the afternoon, or later in the day.

The pelvic floor

The floor of the pelvis is made up of layers of muscle and other tissues. There are three muscles which form the pelvic floor and they are collectively called the levator ani, which means simply 'to lift the anus'. These pelvic floor muscles (see Figure 1.2) stretch like a hammock from the tailbone at the back to the pubic bone at the front. Their main function is to act like a diaphragm to support the contents of the pelvis, particularly the bladder and bowel, and the uterus in the female. The pelvic floor muscles also surround the urethra, vagina and rectum as they pass through to the exterior. In the context of this book, the pelvic floor muscles play an important role in bladder and bowel control by contributing to both the rectal sphincter and the urethral sphincter mechanisms, thus providing bladder neck support and supplementary urethral closure.

Generally, the pelvic floor muscles are made up of about two-thirds slow-twitch muscle fibres, which allow them (like the sphincters) to stay continuously tonic (working), underlying their role in supporting the pelvic organs. The specific pelvic floor muscles around the urethral sphincter are a mixture of fast-twitch and slow-twitch muscle fibres that raise urethral closure pressure during periods of increased intra-abdominal pressure (such as during sustained lifting). The presence of fast-twitch fibres means that the pelvic floor muscles can also quickly and reflexly contract to support the urethral sphincter while we are performing sudden heavy lifting, coughing or the like.

The prostate

The prostate is a small, walnut-shaped gland of the male reproductive system. It is located at the neck of the bladder like a collar surrounding the urethra as it descends from the bladder (see Figure 1.1).

The gland produces fluid which provides one of the constituents of semen and becomes part of the ejaculate. This fluid has a role in sperm mobility. During ejaculation, as the sperm enters the urethra, the bladder neck contracts (tightens) to propel the ejaculate down the urethra.

The prostate gradually enlarges with age, creating the potential to cause what is known as benign prostatic hyper-plasia (BPH), or 'enlarged prostate'. Depending on the degree of enlargement, this can constrict the urethra, causing a degree of obstruction and slowing the urine outflow.

There is a large neurovascular bundle between the prostate capsule and the rectum. These nerves relay messages from various centres to both the bladder and the penis. Damage or interference to these nerves during surgery can interfere with both continence and potency.

There is also a large collection of veins surrounding the prostate. The veins are called the dorsal vein of the penis complex. When removing the prostate, surgeons have to be careful not to injure these veins, as they carry a large amount of blood.

Abdominal muscles

For this program to be effective, it is essential that the role of the abdominal muscles and the diaphragm in the management of incontinence is understood.

Recent research has reinforced the empirical observation of the strong link between abdominal muscle activity and pelvic floor muscle activity. There is evidence that transversus abdominis, the diaphragm and the pelvic floor muscles coactivate to form an enclosed abdominal cavity in a response designed to control spinal stability (Hodges, 1999) (Figure 1.4). Further contraction of obliquus externus, obliquus internus and transversus abdominis muscles (Figure 1.4) has been shown to occur automatically during a maximum pelvic floor muscle contraction (Sapsford et al., 2001). In fact, in another study (Sapsford and Hodges, 2001) it was found that increasing strength of abdominal muscle activity was associated with increasing activation of pelvic floor muscles.

This program places a strong emphasis on developing fit abdominal muscles in order to help overload and increase the fitness of the pelvic floor muscles.

In relation to reflex circuitry, and in particular the anticipatory reflex (discussed in the Introduction), experimental evidence has shown that, when arm movement is performed, the onset of transversus abdominis activity precedes that of the deltoid muscle (the shoulder muscle which moves the arm forward) by approximately 30 milliseconds (Hodges and Richardson, 1997).

Further, testing of the diaphragm indicates that shortening of the diaphragm precedes the onset of shoulder movement, providing further confirmation of the mechanical efficiency of the feed-forward activation of the diaphragm (McKenzie et al., 1994).

Nerve supply to the urinary system

The nerve supply of the lower urinary system is complicated. However, some understanding of its functioning is necessary.

There are thirteen reflexes which control bladder voiding and continence. These reflexes are mediated through at least seven command centres, ranging from centres in the brain and spinal cord to nerve centres in the bladder wall, as well as the urethral sphincter and pelvic floor muscles, in a coordinated manner.

Central to efficient bladder control in the male is the internal sphincter of the bladder (see Figure 1.1a) (there is no internal sphincter in females). This is controlled by the autonomic nervous system (which controls the body's involuntary movements). All neural sensory fibres from the pelvic region ultimately feed into what is known as Onuf's nucleus in the sacral cord, which then coordinates and controls the complexities of continence and evacuation of the bladder and bowel.

To further complicate things, the autonomic nervous system is divided into the sympathetic and parasympathetic divisions, or trunks (see Figure 1.5). The sympathetic division allows bladder storage, while the parasympathetic produces a sustained bladder contraction for emptying. When the genitalia are stimulated, impulses reach the spinal erection centre situated in these trunks (the nerves carrying these impulses enter and exit the spine at the sacrum outlets, S2 to S4, and thoracic and lumbar vertebrae outlets, T10 to L2), causing the penis to become erect. The pelvic floor muscles (including the anal and urethral external sphincter) are supplied by the pudendal nerves.

With all these factors in mind, it is not difficult to visualise how any interference applied to this sensitive neural network, from childbirth (in the female), surgery or other trauma (to either male or female), could have a marked effect on continence control. (In the case of the male, it can also contribute to erectile dysfunction.)

Coupled with the natural anxiety involved with both the loss of bladder control and sexual function, this situation could very quickly escalate into a syndrome involving serious psycho-social legacies if it is not addressed as quickly as possible.

Normal bladder function

As discussed in Chapter 1, normal bladder capacity is about 500 millilitres. It takes an average of 15–30 minutes for a glass of water to be passed through the system to reach the bladder if the patient is well hydrated. When the bladder fills to about 200 millilitres, the first signal to void is registered in the brain. This normal urge can be suppressed until the bladder fills to about 400–500 millilitres. At this time, the desire is felt again and voiding occurs. If the situation is not convenient, then the bladder can easily defer and eventually accommodate up to 700–800 millilitres.

The normal frequency of voiding is between four and six times a day, and perhaps once a night. This varies with fluid intake, activity and ambient temperature, and can increase to around six to eight times a day in the elderly.

As the bladder enlarges (at about 200 millilitres), stretch receptors in the bladder walls discharge a message to a part of the midbrain (the pons — known as the micturition or urination centre), which has both facilitary and inhibitory capabilities. This message is then relayed on to the cerebral cortex, leading to conscious awareness, so that one feels the urge to void at this point.

If one chooses not to void, reflex bladder contractions subside within a minute or so, and urine continues to accumulate. After about 200–300 millilitres more has collected, voiding generally occurs. On the other hand, at the appropriate time, if one wishes to void, the cortex sends a message via the pudendal and pelvic nerves causing the pelvic floor muscles and urethral sphincter to relax. A few seconds later, another message relayed via the parasympathetic nerves initiates bladder muscle contraction, therefore allowing urine to flow.

Urine should then flow in a steady continuous stream without discomfort. Unless the abdominal wall and pelvic floor muscles are relaxed for voiding, flow will be slow, intermittent and incomplete. There should be no hesitancy or strain; there should be minimal residual in the bladder or urethra; and no after-dribble should occur. If there is some after-dribble, it is usually due to weakness of the muscle which surrounds the urethra (the bulbospongiosus muscle). This is very common in males over the age of 40 and has nothing to do with the prostate. It can be helped by specific exercises.

In order to remain continent, the following are necessary:

• a bladder which is able to remain relaxed while filling, and able to contract to completely empty on voiding;

• a strong sphincter mechanism;

• a pelvic floor strong enough to support the sphincter mechanism;

• an intact neural network system; and

• a healthy vascular system to supply nerves and muscles.

Erectile dysfunction and orgasm

In relation to erectile dysfunction — a well-recognised side-effect of prostate cancer as well as its treatment — many factors are involved which are beyond the scope of this book. However, it is useful to know that, from a diagnostic point of view, they may be classified as psychogenic, vascu-logenic, neurogenic, endocrinologic, diabetic, drug-related, trauma-related and poor pelvic musculature. In relation to this book, if there is a chance that the cause is purely neurogenic, vascular or caused by weak pelvic floor muscles, this program may be helpful in working towards a recovery.

The other associated and useful piece of information concerns male orgasms. The experience of orgasm is independent of sympathetic and parasympathetic activity, which is often compromised during radical prostate surgery, but it does require an intact pudendal nerve, which is rarely involved during prostate surgery (see Figure 1.5) (Mamberti-Dias et al., 1999). So, although radical prostatectomies may interfere with erections, orgasms are nearly always preserved. Of further interest, a transurethral resection of the prostate (TURP) — a treatment for enlarged or benign prostate hyperplasia (BPH) — will interfere with neither erections nor orgasms.

CHAPTER 2

What causes incontinence?

Defining incontinence

Urinary incontinence is defined as the complaint of any involuntary leakage of urine (International Continence Society, 2002).

Urinary incontinence can be a major health problem. Because of the social stigma often associated with it, incontinence has traditionally been under-reported, and many patients are hesitant to discuss the problem with their physician and other health care professionals.

Even though the condition was previously almost exclusively seen in women and older men, in this era of increased detection of prostate cancer in men and the intervention of radical prostatectomy for treatment, post-prostatectomy incontinence (PPI) is also now becoming an increasing problem. All incontinence is troublesome, but PPI is particularly disturbing because it generally occurs in men who had normal continence immediately before surgery. The same could be said for women who develop incontinence after childbirth or surgery.

There are basically four types of incontinence:

• stress incontinence;

• urge incontinence;

• overflow incontinence; and

• mixed incontinence.

Stress incontinence

This occurs when any movement or action that increases pressure in the abdominal cavity results in urine leakage. The condition manifests itself with such activities as coughing, sneezing, laughing, heel impact upon walking or running, changing posture (sitting to standing), sexual activity or passing wind. Because there is often fluid loss caused from impact during sport, sufferers often adopt a more sedentary lifestyle, which can eventually lead to further health issues.

Urge incontinence

When the urge to 'go to the bathroom' is so great you cannot 'hold it', it is referred to as urge incontinence. The bladder muscle (detrusor) contracts in spasm so strongly it squeezes fluid out. The leakage is accompanied, or immediately preceded, by urgency.

(Motor) urge incontinence can also be known as 'unstable or overactive bladder', and can be associated with 'frequency' (frequent voiding). As such, loss of control can also be triggered by, for example, the sound of running water or approaching the front door lock (on the way to the bathroom). Sensory causes can be from urinary infections, stones and cancer.

I have a patient who has urge incontinence and will not leave the house for fear of not being able to make it to the next toilet. Her condition is of such concern to her that she has memorised the locations of all the local public toilets in her area. The urge can be triggered without warning when she hears a steady high frequency sound such as whistling, upon which she will simply 'lose it'.

Overflow incontinence

Also called false incontinence, overflow incontinence is when the bladder never drains completely because either the urethra and/or bladder neck is obstructed or the bladder muscle (detrusor) contracts very poorly. The urine subsequently builds up behind the sphincter and overflows like water over the top of a full drain.

Mixed incontinence

Commonly, components of all these types of incontinence, such as stress and urge incontinence, can occur together. Often, however, one symptom (either stress or urge) is generally more bothersome to the patient than another. Identifying the most annoying symptom is important when targeting diagnostic and therapeutic interventions. Incontinence is not a disease; nor is it a natural part of growing old. Incontinence is a symptom or side-effect of other health concerns, which can range from faecal impaction to brain tumour.

(Continues...)

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Excerpted from Conquering Incontinence by Peter Dornan. Copyright © 2003 Peter Dornan. Excerpted by permission of Allen & Unwin.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Contents

Figures,
Acknowledgments,
Glossary,
Introduction,
Part I Anatomy and physiology: The bladder and the lower urinary tract,
1 How it all works,
Part II Incontinence: Causes and treatments,
2 What causes incontinence?,
3 Conventional treatments for stress incontinence,
Part III Behavioural intervention: A new and physical approach,
4 A new approach: Taking control,
5 Urge incontinence and bladder training,
Part IV Cancer and incontinence: The psychological and social effects,
6 Dealing with the demons: Cancer, depression and beyond,
7 Erectile dysfunction: The meaning of manhood,
Appendix: Pilot study results,
Bibliography,